CUVA Parental Consent & IRB

PARENT INFORMED CONSENT FORM for RESEARCH

Title of Study: An Evaluation of Community-based Promotion of Healthful Recreation in Cuyahoga Valley National Park: A Survey of Riedinger Middle School

Principal Investigator: Myron F. Floyd

INFORMATION

We are asking your child to participate in a research study. The purpose of this study is to learn about what outdoor activities

middle school students like, how often they participate, and where they do them. They will be asked to fill out a survey form

about their outdoor activities. It will take about 15 to 20 minutes. The survey will be done in class.

RISKS

There is nothing risky or personal about the survey. They will not be asked about any personal information.

BENEFITS

Although there are no direct benefits from answering the survey, the results will be used to help understand what kinds of recreation activities middle-school students are participating in outside of school.

CONFIDENTIALITY

The information in the study will be kept strictly anonymous. Data will be stored securely in a locked file cabinet and will also be stored in a password access computer file. No reference will be made in oral or written reports which could link your child to the study.

Your child’s name will only be used to help us keep track of who has completed the survey and to contact them for a second follow-up survey next school year. When the study is complete, all names will be stripped from the files and only a tracking number (in place of your child’s name) will be used for matching or other purposes. 

PARTICIPATION

Your child’s participation in this study is voluntary. They can decline to participate without penalty. If your child decides to participate, he/she can withdraw from the study at any time without penalty and without loss of benefits to which he/she is otherwise entitled. If they withdraw from the study before data collection is completed their data will be returned to them or destroyed at their request.

If you have questions at any time about the study or the procedures, you may contact the researcher, Dr. Myron Floyd, at 919-513-8026. Dr. Floyd is assisting the school and the Cuyahoga Valley National Park with this project. You may also contact Ms. Mary Pat Doorley, Cuyahoga Valley National Park, at 440-546-5995.

If you feel your child has not been treated according to the descriptions in this form, or if their rights as a participant in research have been violated during the course of this project, you may contact Dr. Matthew Zingraff, Chair of the NCSU IRB for the Use of Human Subjects in Research Committee, Box 7514, NCSU Campus (919/513-1834) or Mr. Matthew Ronning, Assistant Vice Chancellor, Research Administration, Box 7514, NCSU Campus (919/513-2148)

CONSENT

If you do not consent to allow your child’s participation in this survey, please sign and have your child return this form to his/her teacher. Your signature acknowledges “I have read and understand the above information. I have received a copy of this form.”

Parent/guardian signature_______________________________________ Date _________________

Investigator's signature______________________________________ Date _________________